To help make the use of prescription drugs safer and more affordable, our plan is now using a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a certain number of days. This gives you the right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA). Based on the FDA’s guidelines and other medical information, our plan developed this program together with Express Scripts, the company chosen to manage our prescription drug benefit.
The following limits are based on a 34-day supply, but our benefit may provide a different supply. For instance, you may be able to get a 90-day supply of your medication through mail order service. Your doctor could also request a prior authorization. If this request is approved, a prior authorization would let you receive more than the recommended quantity.
Drug Quantity Limits
for MCSIG
Prescription Drug Benefit| Name of Prescription Drug | Maximum Quantity |
| Actonel 35 mg | 5 tablets |
| Actonel 5 and 30 mg | 34 tablets |
| Actonel 75 mg | 2 tablets |
| Actonel 150 mg | 1 tablet |
| Actonel with Calcium tablets | 35 Tablets |
| Actoplus Met 15/500mg and 15/850mg | 102 tablets |
| Actos 15, 30, 45 mg | 34 tablets |
| Advair Diskus 100/50, 250/50, and 500/50 with device | 28, 120 blisters |
| Advair HFA | 2 inhalers |
| Aerobid/Aerobid-M 7 grams | 3 inhalers |
| Aerospan 80mcg 8.9 gram | 3 inhalers |
| Aerospan 80mcg 5.1 gram | 1 inhaler |
| Albuterol generic inhaler | 3 inhalers |
| Allegra 180 mg | 34 tablets |
| Allegra 30, 60mg | 68 tablets/orally disintegrating tablets |
| Allegra-D 12 hour | 68 tablets |
| Allegra-D 24 hour | 34 tablets |
| Alora | 10 patches |
| Alupent 14 grams | 3 inhalers |
| Ambien 5, 10 mg | 34 tablets |
| Ambien CR 6.25mg and 12.5mg | 34 tablets |
| Amerge 1, 2.5 mg | 9 tablets |
| Anzemet 50, 100 mg | 1 tablet |
| Arava 10 mg, 20 mg | 34 tablets |
| Asmanex 14 inhalation units | 1 inhaler |
| Asmanex 30, 60, 120 inhalation units | 2 inhalers |
| Astelin Nasal Spray (34 ml bottle) | 2 bottles |
| Atrovent HFA 12.9 grams | 2 inhalers |
| Atrovent inhaler 14.7 grams | 3 inhalers |
| Atrovent nasal spray 0.03% (30 grams), generic | 2 bottles |
| Atrovent nasal spray 0.06% (15 grams), generic | 2 bottles |
| Avandamet 1 mg/500 mg, 2/500, 4/500, 2/1000, 4/1000 | 68 tablets |
| Avandaryl 4mg/1mg, 4mg/2mg, 4mg/4mg, 8mg/2mg, 8mg/4mg | 34 tablets |
| Avandia 2, 4 mg | 68 tablets |
| Avandia 8 mg | 34 tablets |
| Avonex | 4 syringes |
| Axert 6.25 mg | 6 tablets |
| Axert 12.5 mg | 12 tablets |
| Azithromycin | See Zithromax |
| Azithromycin 500mg | 4 tablets |
| Azmacort 20 grams | 3 inhalers |
| Beconase AQ 25 grams | 2 inhalers |
| Betaseron | 15 vials with prefilled diluent syringe |
| Boniva 2.5 mg | 34 tablets |
| Boniva 150 mg | 1 tablet |
| Brovana Inhalation Solution (30 vial carton) | 3 cartons for a 34-day supply |
| Butorphanol tartrate Nasal Spray | 2 spray bottles |
| Byetta 1.2 ml (250 mcg/ml) | 2 syringes |
| Byetta 2.4 ml (250 mcg/ml) | 2 syringes |
| Cabergoline 0.5mg | 10 tablets |
| Catapres-TTS Patches | 5 patches |
| Caverject | 12 vials, kits, or ampules |
| Cesamet | 30 capsules |
| Chorionic gonadotropin 10000 units, generic | 3 vials |
| Cialis 5, 10, and 20 mg | 6 tablets |
| Cialis 2.5mg | 34 tablets |
| Clarinex/Clarinex Reditabs 5 mg | 34 tablets |
| Clarinex 2.5mg Reditabs | 34 tablets |
| Clarinex-D 12 hour | 68 tablets |
| Clarinex-D 24 hour | 34 tablets |
| Claritin 10 mg/Claritin Reditabs 10 mg, Claritin 5 mg chewable tablets | 34 tablets |
| Claritin-D 12 Hour | 68 tablets |
| Claritin-D 24 Hour | 34 tablets |
| Climara, Climara Pro | 5 patches |
| Combivent 14.7 grams | 3 inhalers |
| Copaxone 20 mg kit | 1 kit (30 prefilled syringes) |
| Cordran Tape | 2 rolls of tape |
| Crestor 40 mg | 34 tablets |
| Depo-Provera Contraceptive Injection 150 mg/mL | 1 vial/syringe |
| Depo-Sub Q Provera 104 | 1 syringe |
| Diflucan 150 mg | 2 tablets |
| Ditropan XL 5 mg | 34 tablets |
| Divigel 0.25, 0.5, and 1 grams | 34 packets |
| Dostinex 0.5 mg | 10 tablets |
| Duetact 30/2mg and 30/4mg | 34 tablets |
| Duoneb 3 ml vial | 205 vials (package size 3) |
| Edex | 12 vials or kits |
| Elestrin gel pump | 1 pump |
| Emend 115mg vial | 1 vial |
| Emend 125 mg | 1 capsule |
| Emend 40mg capsule | 1 capsule |
| Emend 80 mg | 2 capsules |
| Emend Bifold Pack | 1 pack |
| Emend Trifold Pack (one 125 mg and two 80 mg capsules) | 1 pack (package size 3) |
| Enbrel 25mg vials | 10 vials |
| Enbrel 25 mg syringes | 10 syringes |
| Enbrel 50mg syringe/auto injectors | 5 syringes/auto injectors |
| EpiPen, EpiPen Jr. | 3 units or 2 twin packs |
| Esclim | 10 patches |
| Estraderm | 10 patches |
| Estradiol transdermal patch | 5 patches |
| Estrasorb | 68 packets |
| Estrogel .06% 50gm | 2 pump bottles |
| Evamist 1.53 mg spray | 2 pumps |
| Factive 320mg | 7 tablets |
| Famvir 125 mg | 21 tablets |
| Famvir 250 mg | 68 tablets |
| Famvir 500 mg | 21 tablets |
| Fexofenadine | See Allegra |
| Flector 1.3% patch | 60 patches |
| Flonase 16 grams | 2 bottles |
| Flovent 50mcg Diskus | 2 inhalers |
| Flovent HFA 44mcg | 2 inhalers |
| Flovent HFA 110mcg | 1 inhaler |
| Flovent HFA 220mcg | 3 inhalers |
| Fluconazole 150mg | 2 tablets |
| Flunisolide 0.025% | 3 inhalers/bottles |
| Fluticasone Nasal Spray | 2 sprays |
| Foradil Aerolizer & 12 capsules in blisters | 1 package (package size 12) 12 caps |
| Foradil Aerolizer & 60 capsules in blisters | 2 packages (package size 60) 120 caps |
| Fosamax 35 and 70 mg | 5 tablets |
| Fosamax 5, 10, and 40 mg | 34 tablets |
| Fosamax 70 mg/75 mL oral solution | 5 bottles |
| Fosamax Plus D 70 mg/2800 IU, 70mg/5600 IU | 5 tablets |
| Frova 2.5 mg | 9 tablets |
| Humira 20 mg and 40 mg syringe/pen | 3 syringes/pens |
| Humira Crohn’s Starter Pack | 3 syringes |
| IB Stat oral spray 30 mL | 14 bottles |
| Imitrex Injection (syringes/cartridges) | 1 kit (2 syringes) |
| Imitrex 4mg injection (syringes/cartridges) | 1 kit (2 syringes) |
| Imitrex Injection (vials) | 2 vials |
| Imitrex Nasal Spray 5, 20 mg | 6 nasal spray devices |
| Imitrex tablets 25, 50, and 100 mg | 9 tablets |
| Intal Inhaler 112 | 2 inhalers |
| Intal Inhaler 200 | 2 inhalers |
| Itraconazole 100mg | 34 capsules |
| Janumet 50/500 mg, 50/1000 mg | 68 tablets |
| Januvia 25mg, 50mg, 100mg | 34 tablets |
| Ketoralac 10 mg | 20 tablets |
| Kytril 1 mg | 2 tablets |
| Kytril solution 2 mg/10 mL | 1 bottle |
| Levitra 2.5, 5, 10, and 20 mg | 6 tablets |
| Lioresal Inthrathecal Refill Kit
1 ampule 10 mg/20 ml 2 ampules 10 mg/5 ml 1 ampule 40 mg/20 ml |
1 kit |
| Lunesta 1mg, 2mg, 3mg | 34 tablets |
| Maxair Autohaler 14 grams | 2 inhalers |
| Maxalt and Maxalt-MLT 5, 10 mg | 12 tablets |
| Menostar | 5 patches |
| Miconazole | See Monistat |
| Migranal 4 mg/ml | 8 spray devices |
| Mobic 7.5 mg | 34 tablets |
| Monistat 1 pre-filled | 1 box |
| Monistat 3 combination pack 200 mg & equivalent | 1 box |
| Monistat 3 suppositories 200 mg & equivalent | 3 (1 box) |
| Monistat 7 combination pack & equivalent | 1 box (7 suppositories, 9 gram cream) |
| Monistat 7 cream and equivalent | 45 grams (1 tube) |
| Monistat 7 cream pre-filled applicators | 7 applicators |
| Monistat 7 suppositories 100 mg & equivalent | 7 suppositories (1 box) |
| Monistat Dual Pak (1200 mg vaginal insert, 9 gram 2% cream) | 1 (1 box) |
| Monistat Dual-Pak (three 200 mg vaginal supp, 15 gram 2% cream) | 1 (1 box) |
| Muse | 12 urethral suppositories |
| Nasacort 10 gram | 3 inhalers |
| Nasacort AQ 16.5 gram | 2 bottles |
| Nasarel 0.025% 25 mL | 3 bottles |
| Nasonex 50 mcg nasal spray 17 gram | 2 bottles |
| NebuPent 300 mg/container | 1 container (inhaler) |
| Neumega | 21 vials |
| Newtek disposable blood glucose meter | 2 meters |
| Nexium 20 mg | 34 capsules |
| Nexium 20 mg packets | 34 packets |
| Noverel 10,000 unit | 3 vials |
| Omeprazole 10 mg | 34 capsules |
| Omnaris 50 mcg nasal spray | 2 bottles |
| Ondansetron 24 mg | 1 tablet |
| Ondansetron, Ondansetron ODT 4 and 8 mg | 12 tablets |
| Ondansetron solution 4 mg/5 mL | 3 - 50 mL bottles |
| Oxybutynin XL 5 mg | 34 tablets |
| Pantoprazole 20 mg | 34 tablets |
| Patanase 0.6% Nasal Spray | 2 bottles |
| PEG Intron Pens/Kit (containing 1 vial each) 50 mcg, 80 mcg, 120 mcg, 150 mcg | 5 pens/vials |
| Pegasys 180 mcg | 5 vials (package size 1) |
| Pegasys 180 mcg Convenience Pack ( 4 vials) | 1 box (package size 1) |
| Pegasys 180 mcg Convenience Pack (4 prefilled syringes) | 1 box (package size 1) |
| Perforomist Inhalation Solution | 2 cartons (120 vials) |
| Plan B | 2 tablets |
| Pregnyl 10,000 unit | 3 vials |
| Prevacid 15 mg, Prevacid SoluTab | 34 capsules or tablets |
| Preven Contraceptive Kit | 1 kit |
| Prevpak patient pack | 14 units (1 package) |
| Prilosec 10 mg | 34 capsules |
| Prilosec 20 mg (Brand) | 34 capsules |
| Proair HFA | 3 inhalers |
| Protonix 20 mg | 34 tablets |
| Proventil Inhaler 17 gram | 3 inhalers |
| Proventil HFA 6.7 gram | 3 inhalers |
| Pulmicort Flexhaler 90 mcg | 2 inhalers |
| Pulmicort Flexhaler 180 mcg | 3 inhalers |
| Pulmicort Respules 0.25 mg/2 mL and 0.5 mg/2 mL | 70 ampules |
| Pulmicort Respules 1 mg/2 mL | 35 ampules |
| Pulmicort Turbuhaler | 2 inhalers |
| Qvar 40, 80mcg (7.3 grams) | 3 inhalers |
| Rebetron Combination, Rebetron 1200, 1000, and 600 Therapy Pak | 2 packages |
| Rebif 22 mcg and 44 mcg | 15 syringes |
| Rebif Titration Pack 4.2ml | 1 package |
| Regranex 0.01%gel 2, 7.5, and 15 gm | 1 tube |
| Relenza 5 mg/blister with inhalation device | 20 blisters |
| Relpax 20 mg and 40 mg | 6 tablets |
| Restasis 0.05% | 64 vials |
| Revatio 20mg | 102 tablets |
| Rhinocort Aqua 32 mcg (120 inhalations) 8.4ml bottle | 3 bottles |
| Rozerem 8mg | 34 tablets |
| Serevent Diskus 28 blisters | 1 package |
| Serevent Diskus 60 blisters | 2 packages |
| Sonata 10 mg | 68 capsules |
| Sonata 5 mg | 34 capsules |
| Spiriva Handihaler 6 capsules (1 blister card) with inhaler device | 1 package |
| Spiriva Handihaler 30 capsules (5 blister cards) with inhaler device | 2 packages |
| Spiriva Handihaler 90 capsules (6 blister cards) with inhaler device | 1 package |
| Sporanox 100 mg | 34 capsules |
| Stadol Nasal Spray 2.5 mL | 2 spray bottles |
| Suboxone 2/.0.5 mg | 102 tablets |
| Suboxone 8/2 mg | 102 tablets |
| Symbicort 80/4.5, 160/4.5 Inhaler | 2 inhaler |
| Symlin 0.6mg/ml | 7 vials |
| SymlinPen 60, 120 pen injector | 8 pens |
| Tamiflu 30 mg | 20 capsules |
| Tamiflu 45 mg | 10 capsules |
| Tamiflu 75 mg | 10 capsules |
| Tamiflu for oral suspension, 25 mL | 3 bottles |
| Terazol 3 | 3 (1 box) |
| Terazol 3 Cream 0.8% | 1 tube (of the 20 gram) |
| Terazol 7 Cream 0.4% | 1 tube (of the 45 gram) |
| Terconazole | See Terazol or Zazole |
| Tilade 16.2 grams | 3 inhalers |
| TOBI 300 mg | 56 ampules |
| Toradol 10 mg | 20 tablets |
| Treximet 85 mg/500 mg | 9 tablets |
| Twinject 0.3mg or 0.15mg Auto-Injector | 3 units or 2 twin packs |
| Valtrex 1 gram | 34 caplets (tablets) |
| Valtrex 500 mg | 34 caplets (tablets) |
| Ventolin HFA 90 mcg (18 grams) | 3 inhalers |
| Veramyst Nasal Spray | 2 bottles |
| Viagra 25 mg, 50 mg, and 100 mg | 6 tablets |
| Vivelle | 10 patches |
| Vivelle-Dot | 10 patches |
| Xopenex HFA | 3 canisters |
| Xyzal | 34 tablets |
| Zazole Cream 0.4% | 1 pack (45 gram) |
| Zazole Cream 0.8% | 1 pack (20 gram) |
| Zazole 80mg Vaginal Supp | 3 (1 box) |
| Zegerid 20 mg | 34 tablets |
| Zithromax for oral suspension 100 mg/5 mL, 15 ml bottle | 2 bottles |
| Zithromax for oral suspension 200 mg/5 mL, 15 and 22.5 ml bottle | 3 bottles |
| Zithromax for oral suspension 200 mg/5 mL, 30 ml bottle | 3 bottles |
| Zithromax tablet or capsule, 250 mg | 8 tablets/capsules |
| Zithromax tablet, 500 mg | 4 tablets |
| Zmax 60 ml | 1 bottle |
| Zofran 24 mg | 1 tablet |
| Zofran, Zofran ODT 4 and 8 mg | 12 tablets |
| Zofran solution 4 mg/5 mL | 3 - 50 mL bottles |
| Zolpidem tartrate 5 and 10 mg | 34 tablets |
| Zomig/Zomig-ZMT 5 mg | 6 tablets |
| Zomig Nasal Spray 5 mg | 6 nasal spray devices |
| Zomig/Zomig-ZMT 2.5 mg | 6 tablets |
| Zyrtec, Zyrtec chewable 5 and 10 mg | 34 tablets |
| Zyrtec-D 12 Hour | 68 tablets |